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Home My WebLink About3512 MAIN ST./RTE 6A(BARN.) (6) . I a MO-1 t � j 'down of Barnstable *Permit# . \J 4 Expires 6 months from issue date .00 Regulatory Services Fee /mod Thomas F.Geiler,Director Building Division . ®) Tom Perry,CBO, Building Commissioner ot 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 7&1 1 Property Address�� / 1 Q t�rl (d n/T k sidential Value of Work s J�®� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address An 741o/I ��00�fn,4iP/ 3,512_ lVlaiN Sf (�(Ai1 I f��N,S�o�>e WI If1 Dr:100 n J Contractor's Name �1' �/1 /1�t N/.L x' Telephone Number .Home Improvement Contractor License#(if applicable) p Construction Supervisor's License#(if applicable) 111-7-5 L;Korkman's Compensation Insurance Check one: ❑ I am a sole proprietorX_ -33573 t,� 'T Lwffthe Homeowner I have Worker's Compensation Insurance JAN 3 0 2007 Insurance Company �,ee -,l��l 5 �� - @ A E/`�F�NSTAELE Workman's Comp.Policy# (/�(� V Qa 17 �L Copy of Insurance Compliance Certificate must be on file. . Permit Request(check box) 1 ❑ Re-roof(stripping old shingles) All construction debris will be taken to =' i caUU CD ❑Re-roof(not stripping. Going over existing layers of roof) { =; CD ❑ Re-side c C J r- Replacement Windows/doors/sliders. U-Value I(maximum.44) M *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic, onservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of e Ho re Improvement Contractors License is required. SIGNATURE: rld\ I Q:Forms:expmtrg Revise061306 The Commonwealth'ofMassac husetts Department of Industrial Accidents ! Office of Investigations 1 `r g 600 Washin ton Street }��'` Boston,111A 02111 www.inass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual); LX � Address: 13 a 5 A1 f por+ ied. City/State/Zip: o a�.D Phone #: a&6�� ,4820 ArI an employer? Check the appropriate bog: Type of project(required): 1. m a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the•sub-contractors 6' New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees " These sub-contractors have 8. []Demolition working for me in any capacity, workers' comp:insurance, g, ❑Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its requiie'd.] officers have exercised their 10.❑Electrical repairs or additions 3,❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. C. 152, §1(4),and we have,no 12.❑Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp.insurance required.] . 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub contractors and their workers'comp,policy information. am an employer that is providing workers'compensation insurance for my l employees. Below is the policy and job site . 'nformation. assurance Company Name: ,p e/des 0 'olicy#or Self-ins.Lic.#: e 0 2 3 92 t ' Expiration Date: ob Site Address: d542 /VI& S-F (d,171* -0-9 ' City/state/Zip; attach a copy of the workers' compensation policy declaration page (showing the-policy number and expiration date). . ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine Ef up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of avestigaticns of the DIA for insurance coverage verification. 'do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correc4 i ature: Date: 'hone Official use only, Do not write in this area,,to be completed by city or to official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person:--- I M Me#; • I -Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees, Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint enterprise,and including the Iegal representatives of a deceased employer, or the receiver or trustee of an individual;partnership, association.or other legal entity,employing employees.'However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an'employer." .MGL chapter 152-, §25C(6)also states,that"every state or local licensing agency shall withhold the issuance er renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required," Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s),of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance, If an LLC or LLP does have employees,a policy,is required. Be advised that this affidavit may be submitted to.the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have-any questions regarding the law or if youare required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is.complete and printed legibly. The Department has provided.,a space at the bottom of the affidavit for you to fill out the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permitflicense number which will be used as a reference number. In addition,an applicant thafniust submit multiple permit/license-applications in any given year,need only submit one affidavit indicating current policy.information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.adhere a home Owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc,)said person is NOT required to complete this affidavit. The Office of investigations would like to thank you in advance for your cooperation and should you have any questions, Please do not hesitate to give us a can, The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of lndu tr al Accidents Office of Juvestigatic�ns 600'washfilgton Street Bostoh,MA 02111 Teel. # 617-72-7-4900 ext 40.6 or 1-8-77-M- ASSAFB Fax.##617-727-'�?49 Revised 5-2b-OS . w.ww.mass.gov1dia DATE(MM/DDIYYYY) ACORD CERTIFICATE OF LIABILITY (INSURANCE PELLA-1 7 07/11/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Preston Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1350 Division Rd suite 303 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO Box 810 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. East Greenwich RI 02818-0810 Phone:401-886-8000 Fax:401-885-1700 INSURERS AFFORDING COVERAGE NAIC# INSURED PFR Acquisition, LLC INS'URER A: Peerless Insurance Company 24198 dba: Pella Windows & Doors INSURER 1325 Airport Road Acquisition INSURERC: LLC 1325 Airport Rd INSURER Fall River MA 02720 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGAT HMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICLTR NSR TYPE OF INSURANCE POLICY NUMBER DATE�(MMIDDIYY) DATE(MMIDD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A X COMMERCIAL GENERAL LIABILITY CBP8022572 05/01/06 05/01/07 IS'RE MISES(Eaoccurema). $300,000 CLAIMS MADE X❑OCCUR MED EXP(Any one person) $10,000 X EBL - PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY jEa LOC Emp Ben. 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A ANY AUTO BA8022972 05/01/06 05/01/07 (Ea accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS I BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLALIABILITY EACH OCCURRENCE $10,000,000 A X OCCUR 7CLAIMSMADE CU8024072 05/01/06 05/01/07 AGGREGATE $ 10,000,000 $ DEDUCTIBLE - $ X RETENTION $10,000 $ WORKERS COMPENSATION AND X TORY LIMITS ER EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE WC8023972 05/01/06 05/01/07 E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,00 0 If yes,describe under E.L.DISEASE-POLICY LIMIT $1,000,000 - I SPECIAL PROVISIONS below -- OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWNBAR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of Bans table I NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Attn: Building Division IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 200 Main Street Hyannis MA 02601 REPRESENTATIVES. gUTHO (ZED RE��TIVE ACORD 25(2001108) ©ACORD CORPORATION 1988 r� ✓die iiom�noo2ureal� o�../UCa4daa/u�be�d � . �\ Board of Building Regulations and Standards License or registration valid for inJividul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Regi!trAtion,.._. 9840 Board of Building Regulations and Standards EXprat`on 2 2008 One Ashburton Place Rm 1301 fE 1 � Boston,Ma.02108 Tyol ..1d'Liability Corporation PELLA WINDO\�'," DO?R STEPHEN. DICKIySS' , 1325 AIRPORT ROAD F " — FALL RIVER,MA 02720 SOL Administrator No valid without signature III eannoruuPa � o�/ ioouc�icraa . Lacet►5s: C4u'`k3`Rl1TiC1il SUFF+IRV1OR 9M. 66 Tr.no. 17237 12 BJR C ;• 'Camrniss�o�ei� /' •; . 4 i y f :S